HomeMy WebLinkAbout- Septic Pumping Slip - 23 FOREST STREET 11/26/2018 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 41 TOWN Cur ORI H ANDOVER
�iEALT[I DFARI'MENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe bled, but the
information,must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use. The$ystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facifity InforMatilon
1. System Location: Left/Right front of house, Left Left./right side of house, Left I
Right side of building, Left Right front of buildifig, Left Right rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner
Name*
Address(if different from location)
Cityfrown Statw---) ip Code
Telephone Number
.B. Pumping keeord
1. Date of Pumping :>
Date QuanW Pumped: Gallons
3. Type-of system: El Cesspool($) eptic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E3"Yes El No If yes, was it cleaned? 0_re_; 1_:�1 No
i
5. Condition of Sysl e em.- k& 4 K '� (/�
S. System Pumped By:
Nell.Batesbn F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca*' contente,were disposed:
Loco
Lowell Waste Water
-pEaii�
4SIgn Hbulew Cate
tMrm4.doc-06/03 System Pumping Record-Page 9 of i